Hiccups

One of the most non-specific conditions for a physician to treat is hiccups (singultus). They usually have a very obscure cause and at times can underlie serious diseases.

A young man (non-diabetic/non-hypertensive) diagnosed with malaria presented with tiring non-stop hiccups. He was investigated three days back and the peripheral blood smear demonstrated vivax parasites. He was on artesunate along with other supportive care. He came at 11pm in the casualty and complained that his hiccups were non-stop, present since afternoon (post-lunch) and had caused him considerable exhaustion. He had no other complaints.

Luckily, he responded to injectable metaclopromide within minutes.

Another patient presented with features of gastric acid reflux disease and exhausting hiccups. However, his chief complaint was acidity, from which he wanted immediate relief. An intramuscular injection of rantidine allayed his acidity, but hiccups continued. This man was otherwise normal. I thought of giving him dispersible domperidone tablets; his hiccups stopped 10 minutes after keeping the tablet under his tongue.

I read up few papers on hiccups, their cause and treatment. Most of the literature has treatment based on trial and error; others consist of success stories (such as mine) without much backing. There is hardly any paper which does not mention remedies put forth by folk medicine. In fact, this adds spice to the otherwise boring allopathic life.

Folk medicine has described various home-remedies to get rid of hiccups – from ‘gulp down two teaspoons of sugar’ to ‘have someone startle you with a loud boo!’ Indian folk medicine also prescribes various techniques such as drinking ice cold water or pressing one’s eyeballs gently. Pulling one’s tongue has been suggested as a good alternative. They probably have a scientific basis (like pressing one’s eyeballs stimulates vagal activity).

Good old Harrison does not have much information on treatment of hiccups. Adam’s & Victor’s Principles of Neurology (8th edition) mentions baclofen for persistent cases. Bradley Neurology in Clinical Practice does not mention anything specific. Goetz textbook of Clinical Neurology (3rd edition) has arguably the best line of management:

1. Chlorpromazine 25 – 50 mg IV or 50 mg per orally
2. Metaclopromide 10 mg IV or 10 mg per orally TID

Some published papers provide excellent views (historical and current medical) on hiccups. There are charts on various drugs that are effective (including atropine) and many authors have given protocols for treating intractable kind of hiccups. A case study is the most interesting of the lot – it’s about a man who was instantly relieved from persistent hiccups after a sexual intercourse!

Suggested reading:
1. A paper from British Medical Journal – ‘Management of Intractable Hiccups’.
2. A historical note on hiccups.
3. A paper describing various causes of hiccups.
4. A case report describing sexual intercourse as a potential cure for intractable hiccups (wow!).